CASE REPORT J Nepal Med Assoc 2018;56(210):625-8

CC BY OPEN ACCESS

Perforation Peritonitis at High Altitude

Bhawana Amatya,1 Paleswan Joshi Lakhey,2 Prativa Pandey1

1CIWEC Hospital and Travel Medicine Center, Lainchaur, Kathmandu, Nepal, 2Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.

ABSTRACT

Trekkers going to high altitude can suffer from several ailments both during and after their treks. Gastro-intestinal symptoms including nausea, vomiting, and abdominal pain are common in high altitude areas of Nepal due to acute mountain sickness or due to a gastro-intestinal illness. Occasionally, complications of common conditions manifest at high altitude and delay in diagnosis could be catastrophic for the patient presenting with these symptoms. We present two rare cases of duodenal and gastric perforations in trekkers who were evacuated from the Everest trekking region. Both of them had to undergo emergency laparotomy and repair of the perforation using modified Graham’s patch in the first case and distal gastrectomy that included the perforated site, followed by two-layer end-to-side gastrojejunostomy and two-layer side-to-side jejunostomy in the second case. Perforation peritonitis at high-altitude, though rare, can be life threatening. Timely evacuation from high altitude, proper diagnosis and prompt treatment are essential for taking care of such patients. ______

Keywords: duodenal ulcer; Everest; hypoxia; mountaineering; trekking. ______

INTRODUCTION

The extreme altitude in the Himalayas of Nepal lure life-threatening condition, hence demands immediate trekkers and tourists every year to challenge themselves attention. to new realms. While high altitude can affect virtually all systems of the body, trekkers rescued from high- This article focuses on the gravity of this illness so as to altitude can present with a myriad of symptoms apart spread awareness about the spectrum of disorders that from the usual altitude illness. In this case series, we increasing altitude can generate. highlight the stories of two Everest trekkers who had to curtail their treks due to acute abdomen, namely perforation peritonitis. CASE REPORT

At a constant temperature, the volume of gas is inversely A 45-year-old Korean male had been trekking in the proportional to the pressure it receives according to Everest region for seven days when he developed Boyle’s Law.1 Decreased barometric pressure at high- severe nausea and vomiting at Lobuche (4900m). He altitude2 causes hyper-inflation of the hollow viscera, ______which may cause them to perforate.3,4 Perforation Correspondence: Dr. Bhawana Amatya, CIWEC Hospital peritonitis, though unusual after trekking can be a and Travel Medicine Center, Lainchaur, Kathmandu, Nepal. Email: [email protected], Phone: +977-9849944888.

JNMA I VOL 56 I ISSUE 210 I MAR-APR, 2018 625 Amatya et al. Perforation Peritonitis at High Altitude took buscopan and ascended to Gorakshep (5140 m). While in Gorakshep, he had further episodes of vomiting, ongoing nausea and severe abdominal cramps. He was given Prednisolone 10mg, Sildenafil, Acetazolamide 250mg and Ibuprofen 400mg by a trekker doctor friend with concern of altitude illness. As his symptoms continued, he was carried down on the back of a horse from Gorakshep to Pheriche (4200 m). After an overnight rest, a helicopter brought him to Lukla and then to Kathmandu (1330m).

At CIWEC Hospital in Kathmandu, he continued to have repeated vomiting and upper abdominal pain of severity 10/10. He had pulse of 62/min, blood pressure of 160/90 mmHg, temperature of 37.3ºC and oxygen saturation Figure 2. Intra-operative findings of perforation in on room air of 99%. He was ill looking and appeared anterior wall of the first part of the duodenum. dehydrated. Lungs were clear and cardiac examination was normal. Abdominal examination initially revealed epigastric tenderness which was later followed by guarding and rigidity. Upright X-ray chest showed gas CASE REPORT 2 under both hemi-diaphragms (Figure 1). He was referred to surgery and emergency exploratory laparotomy was A 70-year-old previously healthy American male done. He was found to have a solitary perforation in the trekker was seen after helicopter evacuation from anterior wall of the first part of the duodenum which Deboche (3800m) in the Everest trekking region. He was repaired using modified Graham’s Patch (Figure 2). had been trekking for thirteen days, climbing up the Helicobacter pylori (H. pylori) antibody in the serum was Kala Pathar (5580m) and reaching the Everest Base positive and he was given triple therapy for H. pylori Camp (5364m). On the twelfth night of his trek, he eradication. Post-operative recovery was uneventful initially developed shoulder pain then woke up early in and he returned to Korea. the morning with severe abdominal pain. The abdominal pain was aggravated by sudden movement, touching or deep breathing. He had been having diarrhoea until 5 days ago but had no bowel movement for the last 3 days. He had been taking Tab. Ciprofloxacin 500 mg twice daily for 5 days, which he had stopped 5 days ago, Cap Loperamide, Ibuprofen 600 mg twice as well as Hydrocodone 10 mg to relieve his pain. However, the pain had not subsided and he had to be helicopter evacuated to Kathmandu.

Upon arrival at CIWEC, his vitals were blood pressure 120/80 mmHg, pulse 88/min, temperature 36.7ºC,

respiratory rate 22/min, spO2 98% in room air. He appeared dehydrated. His abdominal examination revealed diffuse severe tenderness with rigidity and sluggish bowel sounds. Chest, cardiovascular, and Figure 1. X-ray chest erect showing gas under both neurological examinations were normal. Chest X-ray hemi-diaphragms. erect with both domes of diaphragms showed gas under the right dome of diaphragm suggestive of pneumo-peritoneum (Figure 3). Emergency surgical consultation was followed by emergency laparotomy at another facility. One litre of sero-purulent fluid was present in the peritoneal cavity with large perforation in the pre-pyloric region in the anterior wall (~2 cm) with surrounding induration (Figure 4). Thorough lavage of the peritoneal cavity was done with 5 litres of warm saline. He underwent distal gastrectomy that

626 JNMA I VOL 56 I ISSUE 210 I MAR-APR, 2018 Amatya et al. Perforation Peritonitis at High Altitude included the perforated site, followed by two-layer DISCUSSION end-to-side gastrojejunostomy and two-layer side to side jejunostomy. Two drains were placed– one in Symptoms of acute mountain sickness including Morrison’s pouch and the other in the pelvis. headache, nausea and vomiting are common in trekkers to high altitude areas of Nepal where rates of AMS can Post-surgery, he was kept in the intensive care unit at be up to 50%.5 These symptoms are equally common CIWEC, required inotropic support with Noradrenaline due to a gastro-intestinal infection which is the most which was later tapered and stopped on third post- common ailment in travellers to Nepal.6,7 Our first patient operative day. He was also kept under antibiotics had symptoms of nausea, vomiting initially with later Piperacillin/Tazobactam, oxygen and pain management. development of abdominal pain. He was initially treated He developed pneumonia on the second post-operative for AMS with steroid and Ibuprofen both of which could day. He was hospitalized for ten days, then returned to have made the duodenal ulcer worse. Helicobacter his home country after his condition was stable. About pylori infection is known to be associated with peptic three weeks post his arrival in the US, he developed ulcer disease8 and this patient was positive for this an abscess on the site of the surgical incision. He was infection. He was evacuated to Kathmandu promptly hospitalized there for a week and was treated with where he was noted to have a surgical abdomen. Prompt several different antibiotics for a month. Thereafter, he treatment of perforated duodenal ulcer led to a speedy recovered and has remained in good health. recovery. H. Pylori infection, combined with NSAIDs and steroid use at high altitude most likely led to the DU with perforation. He did well following surgery. In our second patient, it is possible that NSAID use had a role in causing gastric perforation. Although perforation peritonitis was recognized quickly in our facility, his advanced age might have led to a complicated course post operatively.9

Medical facilities for performing surgeries do not exist in high altitude areas of Nepal and patients have to be evacuated to lower altitudes for prompt diagnosis and treatment. Helicopter rescues from the mountains are readily available in Nepal and this may be the reason patients survive life threatening conditions.10,11

Figure 3. Plain radiograph of chest erect view Did hypoxia at high altitude have a role in causing showing gas under right dome of diaphragm. perforation in these patients? Increased incidence of gastric ulcers and bleeding have been described in Chinese lowlanders who moved to high altitude to work on a railroad project.12 The risk increased in persons who consumed large amounts of alcohol, took aspirin or dexamethasone.12,13 Gastric mucosal lesions and gastrointestinal bleeding from peptic ulcers have also been noted in Japanese mountaineers.14 Perforation of duodenal ulcer was noted in pilgrims from India during “Shri Amarnath Ji Yatra” where devotees do a difficult trek of 40 km to reach a holy cave at 4200 m.15 Although increased incidence of gastric mucosal lesions have been noted in trekkers and mountaineers from the eastern cultures, this has not been a prominent finding in the Western literature. If one looks at the various organ systems of the body at extreme altitudes, most of them show some impairment attributable to hypoxia for example reduced gastrointestinal absorption.16 Figure 4. Intra-operative findings of perforation on the pylorus of the stomach. Case reports from patients returning from air travel, which exemplify high altitude, have shown that high altitude predisposes to causing gaseous expansion and sometimes perforation in the digestive tract.3,17 JNMA I VOL 56 I ISSUE 210 I MAR-APR, 2018 627 Amatya et al. Perforation Peritonitis at High Altitude

Healthcare providers and trekkers should be aware Conflict of Interest: None. of the wide array of illnesses that may appear in the extreme conditions of high-altitude. Consent: JNMA Case report consent form was signed by the patient and the original is attached with the Abdominal cramps and vomiting can also be symptoms patient chart. of acute mountain sickness but as in these cases, with wide differentials in mind, life-threatening emergencies can be recognized and treated promptly.

REFERENCES 9. Christiansen P, Jensen HE, Amdrup E, Fenger C, Lindskov J, Nielsen J, et al. Gastric ulcer in old age. Acta Chir Scand. 1. West JB. Robert Boyle’s landmark book of 1660 with the first 1978;144(7-8):491-4. [PubMed| PMC] experiments on rarified air. Journal of Applied Physiology. 2005;98(1):31-9. [PubMed] 10. Shlim DR, Houston R. Helicopter rescues and deaths among trekkers in Nepal. JAMA. 1989;261(7):1017-9. [PubMed] 2. B West J, Lahiri S, Maret K, Peters R, J Pizzo C. Barometric pressures at extreme altitudes on Mt. Everest: Physiological 11. Williams KL. Exped 2010--the challenges of an expedition significance. 1983. [PubMed] doctor. J R Army Med Corps. 2011;157(1):121-3. [PubMed | PMC] 3. Kenfack R, Debaize S, Sztern B, Joukovsky P. [Perforation of a hiatal hernia after a high altitude flight]. Rev Med Liege. 12. Wu TY, Ding SQ, Liu JL, Jia JH, Dai RC, Zhu DC, et al. 2007;62(3):144-6. [PubMed | PMC] High-altitude gastrointestinal bleeding: An observation in Qinghai-Tibetan railroad construction workers on Mountain 4. Morgan J, Sadler MA, Yeghiayan P. Spontaneous Tanggula. World J Gastroenterol. 2007;13(5):774-80. [PubMed pneumomediastinum in a patient with recent air travel. | Full Text] Emergency Radiology. 2007;14(6):457-9. [PubMed | DOI] 13. Subedi BH, Pokharel J, Goodman TL, Amatya S, Freer 5. Hackett PH, Rennie D, Levine HD. The incidence, L, Banskota N, et al. Complications of steroid use on Mt. importance, and prophylaxis of acute mountain sickness. Everest. Wilderness Environ Med. 2010;21(4):345-8. [PubMed Lancet . 1976;2(7996):1149-55. [PubMed] | Full Text]

6. Greenwood Z, Black J, Weld L, O'Brien D, Leder K, 14. Sugie T, Adachi M, Jin-Nouchi Y, Matsubayasi K. Von Sonnenburg F, et al. Gastrointestinal infection Gastroduodenal mucosal lesion at high altitude. Japanese among international travelers globally. J Travel Med . journal of mountain medicine. 1991;11(1):55-8. [Full Text] 2008;15(4):221-8. [PubMed] 15. Mir IS, Mir M, Ahmed M. Profile of non traumatic surgical 7. Pandey P, Bodhidatta L, Lewis M, Murphy H, Shlim DR, disorders found in the pilgrims/trekkers travelling to Shri Cave W, et al. Travelers' diarrhea in Nepal: an update Amarnath Ji cave. Indian J Med Res. 2008;128(6):740-3. on the pathogens and antibiotic resistance. J Travel Med. [PubMed] 2011;18(2):102-8. [PubMed | PMC] 16. West JB. Tolerance to severe hypoxia: lessons from Mt. 8. Bashinskaya B, Nahed BV, Redjal N, Kahle KT, Walcott Everest. Acta Anaesthesiol Scand Suppl. 1990;94:18-23. BP. Trends in Peptic Ulcer Disease and the Identification [PubMed] of Helicobacter Pylori as a Causative Organism: Population-based Estimates from the US Nationwide 17. Blumen IJ, Rinnert KJ. Altitude physiology and the stresses Inpatient Sample. J Glob Infect Dis. 2011;3(4):366-70. of flight. Air Medical Journal. 1995;14(2):87-100. PubMed[ ] [PubMed | Full Text]

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